China Launches Cross-Provincial NRCMS Direct Settlement Pilot Across Eight Provinces

Recently, it was reported by the National Health and Family Planning Commission that eight provinces in China have signed service agreements for the inter-provincial networked settlement of the New Rural Cooperative Medical Scheme (NRCMS). Under these agreements, insured patients referred from their home provinces to designated networked healthcare institutions in the partner provinces can enjoy direct settlement and reimbursement at the hospital discharge window, making cross-regional medical expense reimbursement more convenient.

On the 18th, the National Health and Family Planning Commission held a signing ceremony in Beijing for the inter-provincial online settlement of medical expenses under the New Rural Cooperative Medical Scheme (now integrated into the Urban and Rural Resident Basic Medical Insurance). Eight provinces—Liaoning, Jilin, Heilongjiang, Hainan, Sichuan, Guizhou, Shaanxi, and Gansu—signed service agreements to enable this inter-provincial online reimbursement system.

An official from the Department of Primary Health Care under the National Health and Family Planning Commission stated that this signing marks the official launch of the pilot program for cross-provincial online settlement of medical expenses under the New Rural Cooperative Medical Scheme.

It is understood that the inter-provincial agreement signed on this occasion clearly defines the responsibilities and obligations of the participating provinces and the provinces where medical services are received, and standardizes operational procedures such as referral, designated medical care, advance payment, verification, and reimbursement.

Under the agreement, patients are required to pay only their out-of-pocket expenses upon discharge and settlement. The portion reimbursed by the New Rural Cooperative Medical Scheme (NRCMS) fund is settled between the healthcare institution and the provincial-level NRCMS settlement center in the place where medical services were received, with final clearing conducted among the provincial-level NRCMS settlement centers.

In June this year, the National Health and Family Planning Commission, in conjunction with the Ministry of Finance, formulated the “Implementation Plan for Networked Settlement of Cross-Regional Medical Expenses under the New Rural Cooperative Medical Scheme (NRCMS) Nationwide.” The plan explicitly stated that by 2016, the national and provincial NRCMS information platforms would be improved, the NRCMS cross-regional medical care information system would be basically established, direct settlement for intra-provincial cross-regional medical care would be achieved, and pilot programs would be launched for the settlement of medical expenses incurred at designated out-of-province healthcare institutions by NRCMS patients referred for hospitalization. By 2017, settlement of medical expenses for NRCMS patients referred for hospitalization and treated at designated out-of-province healthcare institutions would be basically realized nationwide.

Meanwhile, to actively leverage social forces in the reimbursement of cross-regional medical expenses, the National Health and Family Planning Commission also guided China Life Insurance and China UnionPay to explore a public-private partnership (PPP) cooperation model. China Life Insurance will provide funding to establish a reserve fund for cross-provincial medical expense settlement, while China UnionPay will set up a capital settlement channel, jointly optimizing the cash flow process for cross-provincial medical expense settlement.

“The signing marks another solid step forward in the implementation of cross-provincial online settlement for medical expenses under the New Rural Cooperative Medical Scheme (now integrated into the Urban and Rural Resident Basic Medical Insurance).” Relevant experts pointed out that, in advancing remote settlement services, various regions have also emphasized integration with tiered diagnosis and treatment systems. This approach not only standardizes healthcare-seeking order but also alleviates patients’ financial burden from upfront payments, thereby enhancing the efficiency and management level of the New Rural Cooperative Medical Scheme.

Given the current imbalance in the allocation of medical resources in China and the fact that a tiered diagnosis and treatment system has not yet been established, the implementation of a cross-provincial reimbursement system for basic medical insurance is particularly crucial. Zhu Hengpeng, Director of the Center for Public Policy Research at the Chinese Academy of Social Sciences, stated that with the networked settlement for out-of-area medical care, patients seeking treatment outside their home provinces can achieve real-time reimbursement, which greatly facilitates access to care. “For instance, a resident from Liaoning Province receiving medical treatment in Hainan Province can settle their bills in real time while in Hainan,” said Zhu.

“Integrating the basic medical insurance systems for urban and rural residents, accelerating the implementation of policies such as nationwide networking of medical insurance and cross-regional settlement of medical expenses, can enhance the portability of medical insurance benefits and make it more convenient for the public to seek medical care,” said Gu Xuefei, Deputy Director of the Medical Security Research Office at the Health Development Research Center of the National Health and Family Planning Commission.

However, there are still disparities across regions in terms of medical insurance systems, pooling levels, drug formularies, and reimbursement caps. Taking the basic medical insurance system for urban employees as an example, while city-level pooling has been achieved in 90% of prefecture-level cities, provincial-level pooling has not yet been realized. The current pooling structure introduces significant complexity to cross-regional settlement.

“Whether cross-regional network connectivity and settlement can be achieved appears to be a technical issue, but in reality, it stems from policy inconsistencies across regions.” Experts pointed out that the relatively low level of pooling in the basic medical insurance system remains a major obstacle to nationwide networking and out-of-area medical expense settlement. To achieve nationwide connectivity and out-of-area settlement for basic medical insurance, it would be optimal to implement unified policies across China in the future.

It is recommended that relevant ministries and commissions promptly coordinate medical insurance policies and standard benefit packages across regions, elevate the level of pooling, mitigate the impact of regional disparities, and unify the catalogs for reimbursable medical services and pharmaceuticals, reimbursement rates, and settlement methods. These measures will remove obstacles to facilitating real-time cross-regional settlement of medical expenses and enhancing cost supervision. More importantly, healthcare reform should continue to prioritize a more balanced allocation of medical resources, guide patients to seek care appropriately, and thereby reduce the demand for cross-regional medical treatment.

By Economic Information Daily